Objective: To identify barriers and facilitators to amputation prevention in a rural state using a mixed methods approach integrating spatial epidemiology, regression analysis, and qualitative methods.
Methods: We conducted a sequential explanatory mixed methods study in West Virginia (WV), the only state entirely within Appalachia and among the most rural in the U.S. Quantitative analysis of 2011-2016 hospital discharge data from the State Inpatient Database (HCUP) identified geographic disparities in DM/PAD-related amputation using Bayesian spatial hierarchical modeling and multivariable regression. Qualitative interviews and focus groups were conducted with patients, caregivers, and providers from high-risk zip codes to explore barriers and facilitators to limb preservation. Thematic analysis was used to identify emergent themes.
Results: Amputation rates in WV were geographically clustered, with major amputations occurring at 5 per 1,000 and minor amputations at 7 per 1,000 patients. Regression models showed increased risk for those with PAD complicating diabetes, Medicaid insurance, and rural residence. Sixty-six people participated in interviews and focus groups. Four major themes emerged: 1) lack of patient and provider education, 2) barriers to access and care coordination, 3) geographic and cultural challenges tied to rurality, and 4) treatment non-adherence linked to communication breakdowns and hopelessness.
Conclusions: Disparities in amputation risk are driven by complex, interrelated factors in rural settings. Findings support the need for targeted interventions focused on provider and patient education, care coordination, mental health support, and culturally grounded community engagement. This framework may guide future efforts to reduce amputation rates in other underserved populations.
Keywords: amputation; diabetes; health disparities; mixed methods research; peripheral artery disease; rural health.
Copyright © 2025. Published by Elsevier Inc.